Ensuring that Assessment Tools are Available to Enrollees

Executive Summary

The amount of Medicaid services for enrollees, particularly home and community based services, is increasingly being determined through prior authorization processes that use assessment tools and clinical coverage criteria. These assessment documents may not be made available to the enrollee. However, Medicaid law and due process call for disclosure – whether the decision is made by the Medicaid agency or an entity with which the agency has contracted (e.g., a managed care company or third party administrator). This issue brief discusses the emerging problems, laws and cases that come into play, and make recommendations for advocates.